Pathophysiology and Imaging Findings of Bile Duct Necrosis: A Rare but Serious Complication of Transarterial Therapy for Liver Tumors

Abstract

Bile duct necrosis (BDN) with biloma formation is a type of ischemic bile duct injury that is one of the serious complications associated with transarterial therapies, such as transcatheter chemoembolization therapy (TACE), and radioembolization for hepatocellular carcinoma (HCC) and hepatic arterial infusion chemotherapy (HAIC) for metastatic liver cancer from colorectal carcinoma. In terms of the occurrence of BDN and subsequent biloma formation, ischemic injury to the peribiliary vascular plexus (PBP), the supporting vessel of bile duct epithelium, is thought to be intimately associated. In this paper, we first describe the anatomy, blood supply, and function of the intrahepatic bile duct, and then illustrate the pathophysiology of BDN, and finally present the imaging findings of BDN. Under the process of BDN formation, ischemia of the PBP induces the disruption of the bile duct epithelial protection mechanism that causes coagulation and fibrinoid necrosis of the surrounding tissue by the detergent action of exuded bile acids, and eventually a biloma forms. Once BDN occurs, persistent tissue damage to the surrounding bile duct is induced by imbibed bile acids, and portal vein thrombosis may also be observed. On pre-contrast and contrast-enhanced computed tomography (CT), BDN shows similar findings to intrahepatic bile duct dilatation, and, therefore, it is sometimes misdiagnosed. Differentiation of imaging findings on CT and ultrasound (US)/magnetic resonance (MR) imaging/MR cholangiopancreatography (MRCP) is important for correct diagnosis of BDN.

The Risk Assessment and Clinical Research of Bile Duct Injury After Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma

“…The diagnosis of bile duct injuries had been validated by multidisciplinary team physicians in view of comprehensive evaluation of imaging features, laboratory data and clinical manifestation of conflicted patients. 28 , 29 …”

Iatrogenic Complications and Management of Biliary Interventions

“…15 Because persistent tissue damage to the surrounding bile duct is induced by imbibed bile acids, portal vein thrombosis may also subsequently occur. 15 Although bile duct necrosis and biloma can usually be treated conservatively, in the presence of symptoms such as moderate or severe infection or interval growth of the biloma, prompt treatment is essential to avoid lethal abscess formation and sepsis. 15 Biliary complications following radioembolization include biliary necrosis, biloma formation, abscess formation, biliary strictures, biliary caval fistula, and radiation cholecystitis.…”

Prediction of bile duct injury after transarterial chemoembolization for hepatocellular carcinoma: Model establishment and verification

“…Specific imaging findings were as follows: 1) imaging diagnosis of bile duct dilatation revealed bile duct shadows distributed in the liver lobe or a segment along the Glisson's sheath and running along the portal vein, which might be accompanied by congestion and edema; 2) imaging diagnosis of the hilar biliary stricture was based on magnetic resonance cholangiopancreatography, and the original MRI images showed hilar bile duct filling defect performance or different degrees of stenosis with or without bile duct dilatation; 3) imaging diagnosis of biloma revealed circular, isolated, or polycystic low-density areas accompanied by signs of infection or quasi-circular low-density areas distributed along the Glisson's sheath, which communicated with the bile duct. Bile duct injury caused by DEB-TACE was defined as any one or more of the aforementioned imaging findings combined with laboratory tests of AKP, GGTP, TBil and DBil (14). It should also be differentiated from bile duct changes due to tumor invasion, include imaging manifestations, history of TACE treatment, morphology and occurrence time of bile duct dilatation.…”

“…Due to the lack of effective approaches, treatment outcomes and prognosis of ischemic bile duct injury remained unsatisfactory (12). Several studies have described the pathophysiology, risk factors, imaging findings, and clinical significance of bile duct injuries (13,14); however, predictive factors of bile duct injury after DEB-TACE have received little attention. Therefore, this retrospective study analyzed the incidence of bile duct injury after DEB-TACE and by screening potential risk factors, we developed a nomogram prediction model for postoperative bile duct injury among patients with HCC undergoing DEB-TACE.…”